Fall 2018 Registration Form
Mail or drop off to: NSSRA | 3105 MacArthur Blvd., Northbrook, IL 60062
Fax: (847) 509-1177 • Email: [email protected]
Please be sure to include check or credit card information.
PARTICIPANT INFORMATION
Participant’s Name: ____________________________________________________________ Age: _______ Grade: ______ New Participant? Yes
No
If you answered yes or if any information has changed since last season, please complete the fields below:
Address: ______________________________________________________ City: ____________________________________ Zip: _________________
Primary Contact Name/Phone: ___________________________________________________ Email: ___________________________________________
Primary Emergency Contact Name/Phone: ___________________________________________________________________________________________
Participant’s School/Work: ___________________________________________ Teacher/Contact Name: __________________________________________
School/Work Phone: ____________________________ School Dismissal Time: _________
Diagnosis: ______________________________________________________________
Participant Requires Medication During Program
REGISTRATION INFORMATION
(Need more space? Flip to the next page.)
In addition to program sites, we have NSSRA pick up and drop off sites for participants. Please list your pick up and drop off codes below (see page 63). When signing up for optional
transportation, enter and total both the program and transportation fees listed on the program write-up. Sections below must be completed to process your registration.
Program Information
Program
Transportation Information
Code
Fee
Northbrook Days Festival | Saturday, August 4 387301-01 FREE
387300-01 FREE
Summer Bash | Wednesday, August 15
Code
387300-51
Fee
Pick Up Site
SUBTOTAL
Drop Off Site
(Program &
Transportation Fees)
FREE
Yes, I would like to make a donation to NSSRA Foundation. To learn more about NSSRA Foundation, go to pages 57 - 58.
Subtotal Fee:
Waiver & Release of All Claims
Please read this form carefully and be aware in registering yourself or your minor child/ward for participation in an NSSRA program, you will
be waiving and releasing all claims for injuries you or your minor child/ward might sustain arising out of said program(s). I recognize and
acknowledge that there are certain risks of physical injury to participants in a program, and I agree to assume the full risk of any injuries,
damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities
connected with or associated with such program (including transportation services and vehicle operation, when provided). I agree to waive
and relinquish all claims I or my child/ward may have as a result of participating in the program against NSSRA and its officers, agents,
servants, and employees. I do hereby fully release and discharge NSSRA and its officers, agents, servants, and employees from any and all
claims from injuries, damage, or loss which I or my minor child/ward may have or which may accrue to me or my child/ward and arising out
of, connected with, or in any way associated with the activities of the program. I further agree to indemnify and hold harmless and defend
NSSRA and its officers, agents, servants, and employees from any and all claims resulting from injuries, damages, and losses sustained by
me or my minor child/ward arising out of, connected with, or in any way associated with the activities of the program. In the event of any
emergency, I authorize NSSRA officials to secure from any licensed hospital, physician and or medical personnel any treatment deemed
necessary for me or my minor child/ward’s immediate care and agree that I will be responsible for payment of any and all medical services
rendered. I have read and fully understand the above Program Details, Waiver and Release of All Claims and Permission to Secure Treatment.
Subtotal from Reverse Side:
Deposit:
Credits:
TOTAL DUE:
OFFICE USE ONLY:
Registration Complete
Date: ____________ Time: ____________
Receipt #: _________________________
EACH REGISTRATION FORM MUST BE SIGNED*
Participant/Parent/Guardian: _____________________________ Date: ___________________ Please Print Name: ____________________________________
*If registering by fax or electronically your facsimile or electronic signature shall substitute for and have the same legal effect as an original form signature.
PAYMENT INFORMATION: This Section Must Be Completed
If paying by check, please fill in your check number here: __________________
If you are using Mastercard, Visa, Discover or American Express, please complete the following section:
Please check one:
Mastercard
Visa
Discover
AMEX
Cardholder Name: _______________________________ Card Number: _______________________________
CVV #: ___________ Exp. Date: ___________ Billing Zip Code: ___________ Amount of Charge: $___________
Authorized Signature: ____________________________________________
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